Does A Controlled Diet Improve Cellulite?:

Abstract

Several researchers have suggested that a targeted diet for reducing the adipose tissue may interfere with the severity of cellulite. Others emphasize that the diet composition seems to play a more relevant role than the calorie profile for weight loss and cellulite control. Objective:The aim of this study was to evaluate the influence of a controlled diet on body composition and cellulite improvement in adult women. Methods: Thirty two healthy women, aged from 25 to 40 were included. They received an orientation for a controlled diet to be followed for 3 months. Assessments were performed at the baseline and the end of the study which included four parameters: 1) Photonumeric cellulite severity scale; 2) Anthropometric measuremets 3) Skin elasticity (Cutometer®) and 4) Collagen density or echogenicity and length of the dermis-hypodermis interface line (ultrasonography-DermaScan®). The data was compared with the Paired T-test, Wilcoxon and Pearson's correlation for statistical analyses. Results: Only 14 completed the study. Although the scores of photonumeric scale reduced, there was no difference in the grade of cellulite severity. There were significant reductions in body measurement. The skin elasticity showed no significant change. On the other hand, the dermal density or echogenicity showed a significant increase in the right and left sides (p = 0.05 and p = 0.005, respectively); however, no difference was observed in the lenght of dermis-hypodermis line. Conclusion: the controlled diet was effective for the reduction of weight and body composition, but despite the increase in dermal collagen density, no clinical effect on cellulite could be detected.

Full text

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I N T E R N A T I O N A L J O U R N A L O F N U T R I T I O NI N T E R N A T I O N A L J O U R N A L O F N U T R I T I O N
ISSN NO: 2379-7835
RESEARCH ARTICLE
Does a controlled diet improve cellulite?
Marques, N.C., Soares, J.L.M., Guadanhim, L.R.S., Sternberg, F.fa, Picosse, F.R., Yarak, S., Bagatin, E.
1. Universidade Federal de São Paulo, Dermatology Department.
Abstract:
Abstract: Several researchers have suggested that a targeted diet for reducing the adipose tissue may interfere
with the severity of cellulite. Others emphasize that the diet composition seems to play a more relevant role than
the calorie profile for weight loss and cellulite control.
Objective:The aim of this study was to evaluate the influence of a controlled diet on body composition and
cellulite improvement in adult women.
Methods: Thirty two healthy women, aged from 25 to 40 were included. They received an orientation for a
controlled diet to be followed for 3 months. Assessments were performed at the baseline and the end of the
study which included four parameters: 1) Photonumeric cellulite severity scale; 2) Anthropometric measuremets
3) Skin elasticity (Cutometer®) and 4) Collagen density or echogenicity and length of the dermis-hypodermis
interface line (ultrasonography - DermaScan®). The data was compared with the Paired T-test, Wilcoxon and
Pearson's correlation for statistical analyses.
Results: Only 14 completed the study. Although the scores of photonumeric scale reduced, there was no
difference in the grade of cellulite severity. There were significant reductions in body measurement. The skin
elasticity showed no significant change. On the other hand, the dermal density or echogenicity showed a
significant increase in the right and left sides (p = 0.05 and p = 0.005, respectively); however, no difference was
observed in the lenght of dermis-hypodermis line.
Conclusion: the controlled diet was effective for the reduction of weight and body composition, but despite the
increase in dermal collagen density, no clinical effect on cellulite could be detected.
DOI : 10.14302/issn.2379-7835.ijn-16-986
Corresponding author:
Samira Yarak, Rua Estado de Israel, 379 ap.81 - Vila Clementino - 04022001 - São Paulo - SP
email: syarakdermato@gmail.com.
Key words: Diet, Cellulite, Carboydrate, Fat Mass, Loss Weight
Received Apr 07, 2016 Accepted Jun 15, 2016 Published July 22, 2016

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Introduction:
Cellulite is a localized skin surface irregularity
that affects 85-98% of women after puberty.1-2 Alquier
and Pavot first described it in 1920 as an unaesthetic
alteration of skin surface secondary to traumatic,
infectious and/or glandular stimuli.3 It is not considered
a disease; therefore it does not affect life expectancy or
involve risk of secondary diseases. However it may
disturbe physical, mental and social wellness, with
psychosocial impacts.1,3-4 It is likely that the
etiopathogenesis is multifactorial, and that the
anatomical and structural changes in the connective
and adipose tissues of women are considered the main
factors.5-11 Some authors have also cited alterations in
microcirculation12-13, hormonal changes, genetic
predisposition and nutritionl as factors as well.14-15
The therapies have common goals such as:
induction of lipolysis in subcutaneous tissue;
improvement of blood flow, skin elasticity and dermal
thickness and reduction of the hypertroph connective
tissue septa in the hypodermis. However, the effects
are limited and temporary, and therefore the results are
variable5,24,42,43.
The role of a specific diet, which reduces the
adipose tissue and thus the cellulite severity is
controversial8. Some authors believe that the diet
composition is more important than the calorie profile
for weight loss.11 Changes in the diet composition, like
removing simple sugars, since they can increase the
level of advanced glycation end products (AGEs) and a
consequent collagen breakdown, could be beneficial.16
Another change could be a higher consumption
of mono and polyunsaturated fatty acids, which is
possibly correlated to the reduction of pro-inflammatory
factors. 17 As well as the increase in nutrients such as
zinc and vitamins A, C and D because these may act in
the epidermis, derme and collagen fibers.18-19 And also,
ingesting more fruit, vegetables and cereals that are
rich in terpenoids and polyphenols, due to its control of
adipocyte differentiation.20,21 These also contain silicon,
which contribuite with the connective tissue
metabolism. 22-26
There are very few studies evaluating the
relationship between dietary patterns and cellu-
lite.However, most of them didn't use the adequate
methodology or were inconclusive. Therefore our
question was if the possible change in the dietary
pattern would reduce the cellulite severity by reducing
the subcutaneous fat and/or improving the dermal
structure.
Material and Methods:
The participants were recruited in the Cosmetic
Dermatology Unit of the Department of Dermatology at
the Federal University of Sao Paulo (UNIFESP) after the
UNIFESP Ethics Review Board approved. They signed
the Consent Form and Photography authorization.
The study design was a therapeutic
interventionl, open, not randomized and evaluator
blinded, including 32 healthy women; aged from 20 to
40. The inclusion criterion was: eutrophic and
overweight (according to Body Mass Index - BMI), with
visable cellulite on the buttocks, grades II or III,
according to Nurnberger-Muller classification5. Exclusion
criteria were: pregnancy or desire to become pregnant;
currently nursing; history or clinical signs of venous
insufficiency, arterial diseases, chronic diseases, mental
disorders, and also have undergone any treatment for
cellulite in the last 6 months, like gluteoplasty or
liposuction in the areas with cellulite.
During their first visit, participants were asked
to fill out a 24-hour diet recall for qualitative analysis of
their dietary pattern. They were also asked about
physical activity, oral contraceptive use and previous
pregnancy. They receveid an oral and written

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orientation for the controlled diet to be followed for 3
months.
The diet was based in the maintenance of a
nutritional balance with a predominance of fresh food,
aimed to increase the ingestion of antioxidants. The
distribution of macronutrients comprised: 55-65 %,
carbohydrate, 20-35% fat and 10-20%, protein. The
original quantitative intake, that was assessed by the 24
-hour recall was maintained. The difference was the
food choices, with a prioritization of the nutritional
quality and, thus, directing the participant to what was
permitted and prohibited (Figure 1). The diet was
characterized by less industrialized food, low content of
saturated and trans fatty acids and low consumption of
simple carbohydrates. The participants were advised to
consume whole-grain foods, avoid sugar and candies,
maintain high levels of animal and vegetable proteins,
eat vegetables and legumes freely and completely avoid
alcohol. They were also instructed to consume vegetable
and red fruit juice once a day. Efficacy assessments
were performed at the baseline and at the end of the
study, except for the diet recall, which was calculated on
the following four days: 01, 30, 60 and 90.
The quantitative analysis was performed by
calculating the distribution of macronutrients in the total
caloric value,polyunsaturated fatty acids and total fibers,
using the Dietwin professional software (version 2979,
2014 / Brazil), which is considered an effective method
to assess the amount of nutrients ingested.
The efficacy parameters included:
Photonumeric cellulite severity scale
At the end of the study, three independent
observers (all dermatologists) conducted a blind
evaluation of before and after through photos that were
taken, using the photonumeric cellulite severity scale
(PSSC).27
To ensure photograph standardization,
participants used similar disposable underwear. Photos
were not taken during the first 4 days of menstruation,
to avoid possible interference of liquid retention. The
photos were taken in a dark room, with a black
background and two points of light located at 0,7m
from the ground, suspended by a tripod and at 1m from
the participant. The camera (Canon EOS - Rebel XTi,
USA) was set on a tripod and located at 2 m from the
participant. They were asked to remain motionless and
Food group Controlled diet
Cereals Eat only whole grains
Breads and Biscuits Eat only whole grain breads, without sugar and hydrogenated fatty
acids
Pasta Not consume
Grains and beans Consume with preparations low fat
Nuts Consume without sugar and salt
Vegetables Consume all colors
Tubers Consume with preparations low fat
Consume without cereals at the same time
Fruits Consume all colors
Beverage Consume tea and water, without sugar
No consume alcoholic drinks
Sugar No sugar added
Fat Consume vegetable oils like olive oil
Meat and eggs Consume with low fat preparations
Dairy produts Consume only yogurt, without sugar
Figure 1: Controlled diet composition

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relaxed with no contraction of the hip and lower limb
muscles. A reference point was marked on the ground to
stand by tagging the carpet which ensured standardiza-
tion of the distances.
Anthropometric measurement
Circumferences of the waist, abdomen and hips
were measured with a non-extensible measuring tape.
The thickness of five skinfolds, at the right side of the
body, with the participant standing, was taken (biceps,
triceps, subscapular, abdominal and suprailiac).28 Sums
at baseline and day 90 were generated, which were later
used as an indirect method to assess changes. Weight
was measured using a simple electronic balance and the
participant reported their height.
Body composition was assessed by bioimped-
ance (BIA 101 Quantum, RJL Systems Detroit, MI, USA),
which is a validated non-invasive method.29 It is a fast
and accurate form to estimate lean mass and fat mass,
and also has relatively low cost.30 This was not
performed during the menstruation period to avoid the
interference of fluid retention.31,32
Skin Elasticity
Skin elasticity was evaluated using a
Cutometer® device (MPA 580, Courage & Khazaka,
Cologne, Germany) on standardized points of gluteal
region, and the biological elasticity (R7 value) was
determined.
Collagen density and length of dermis-
hypodermis interface line
A high-frequency (20 MHz) ultrasound (US)
device (DermaScan® C USB, Cortex Technology ApS,
Denmark) was used, which allows high resolution
sectional skin images up to a depth of 3mm, that show
both epidermis and dermis. From the images is possible
to calculate the echogenicity, which correspond to the
dermal extracellular matrix density 33 , as well as the
length of the line between dermis and hypodermis (the
longer the line, the greater is the protrusion of the
hypodermis toward the deep dermis). The measure-
ments were taken at the same points of gluteal region
that was used for skin elasticity.
Statistical analysis
The data was compared with the Paired T-test,
Wilcoxon and Pearson's correlation for statistical
analyses, using a statistical program (GraphPad - Prism
version 5 - USA). The test used was decided according
to the normal curve, two-tailed. The values were
considered significant for p value< 0.05.
Results:
Out of the 32 women who participated, only 14
completed the study. This represents a dropout rate of
56% (18/32). The main cause of dropout was non-
adherence to the proposed diet (10 women). Other
causes were: absence in the last assessment (7 women)
and unexpected pregnancy (1 woman). Statistically
there was no difference in the BMI at the baseline
between the participants who finished the study (24,
5±3, 1kg/m2) and those who dropped out (28, 4±6, 8
kg/m2,), therefore the BMI was not a cause for the
dropout.
For baseline analysis, the ITT (
intention to treat)
population (n=32) was considered. Table 1 shows the
baseline data, including participants’ mean age, weight
and BMI, pregnancy history and oral contraceptive use.
Table 2 comprises data for the participants’ level of
physical activity, showing that 44% reported a moderate
or intense level and 16% reported light physical activity.
They were instructed to maintain this practice
throughout the study, avoiding the bias of a pattern
change. The sedentaries (40%), were instructed to
remain so until the end of the study.

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The food consumption data recorded in the 24-
hour diet recall at baseline showed that most
participants consumed industrial products, foods with
high glycemic index and rich in saturated fat, more than
twice a day (Table 3).
Photonumeric cellulite severity scale
For data analysis, we considered the mean
values attributed to cellulite severity on gluteal regions,
by three independent observers, at baseline and day 90
by using the PP (per protocol) population. It was
observed that the total scores reduced , but the results
were not significant (right side, p=0.3033; left side,
p=0.3955). Figure 2 shows the cellulite clinical aspect
in the gluteal region of one participant at baseline and
day 90, with no noticeble difference.
Anthropometric data and bioimpedance
Table 4 presents the mean and standard
deviation of the anthropometric measurements and the
percentage of lean mass and fat mass obtained by
bioimpedance. There were significant reductions in body
measurements, such as: weight, BMI, skinfold sum,
waist and abdomen circumferences, percentage of lean
and fat mass. These data demonstrated the effective-
ness of the controlled diet for weight loss and reduction
in body measurements.
Skin Elasticity
The skin elasticity showed no significant change
(right side, p-=0.4409; left side, p=0.3174) when
compared to the mean of the measures at baseline and
day 90 (PP population).
Results from the ultrasonography
Table 5 presents the mean of the measures for
dermal echogenicity and the length of the dermis-
hypodermis interface line, obtained by the US images.
The dermal density showed a significant increase for
both sides (right, p=0.02; left, p=0.005). However, the
length of dermis-hypodermis interface line showed no
significant change. Figure 3 shows the US images of
one participant
Table 1. Mean age, weight, Body Mass Index (BMI);
pregnancy history and oral contraceptive use at
baseline (ITT population)
n=32
Age (years) 32.2±5.0*
Weight (kg) 72.4±3.1*
BMI (kg/m2) 26.7±0.9*
Nulliparous (23/32) 71.9%
Oral contraceptive (14/32) 43.8%
Note: *mean and standard deviation
Table 2. Level of physical activity (ITT population)
n=32
Sedentary (13/32) 40%
Light (5/32) 16%
Moderate (9/32) 28%
Intense (5/32) 16%
Table 3. Food groups in the 24-hour diet recall of the participants at baseline
(ITT population)
n=32 <1x /day 1-2x /day >2x /day
Industrialized food 10% 31% 59%
High glycemic food 10% 50% 40%
Foods with saturated or trans fat 6% 31% 63%
Vegetables 28% 38% 34%

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Figure 2. Cellulite clinical aspect in the gluteal region of one participant at baseline
and the end of the intervention
Table 4. Mean and standard deviation of anthropometric measurements and
percentage of bioimpedance data at baseline and end of intervention (PP population)
n=14 baseline day 90 p - value
Weight (kg) 66.8±11.5 63.0±11.6* 0.0001*
BMI (kg/m2) 24.5±3.1 23.1±3.1* 0.0001*
∑ skinfold (mm) 80.4±24.3 64.4±24.3* 0.0004*
Waist (cm) 75.5±8.5 71.5±7.6* <0.0001*
Abdominal (cm) 85.6±9.3 83.3±7.5* 0.02*
FM (%) 29.3±5.4 27.1±4.7 0.004*
LM (%) 68.1±7.9 72.3±4.9 0.015*
EW (%) 46.5±2.6 46.1±2.6 0.36
Note: * p<0,05 (Paired T-test) - significant values; BMI - Body Mass Index;
∑ skinfold - sum of skinfold thickness of: biceps, triceps, subscapular, suprailiac,
abdominal; FM= Fat Mass; LM= Lean Mass; EW= Extracelular Water
Table 5: Mean and standard deviation of the measures for dermal echogenicity and the length of
the dermis-hypodermis interface line for gluteal regions at baseline and end of intervention (PP pop-
ulation)
n=14 Dermal echogenicity Lenght of the dermis-hypodermis
interface line
Baseline day 90 p-value baseline day 90 p-value
Right 0.23±0.13 0.30±0.14 0.05* 12.61±0.53 12.59±0.49 0.44
Left 0.21±0.11 0.31±0.09 0.005* 12.59±0.53 12.55±0.40 0.73
Note: * p<0,05 (Wilcoxon) - significant values

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Dietary consumption
The quantitative calculation demonstrated that
the participants followed the controlled diet throughout
the intervention period. By observing the macronutrient
distribution, it is possible to verify that the participants
consumed an average of 35% lipids, 47% carbohydrates
and 18% protein from the Total Caloric Values (TCV).
Figure 4 shows a comparison between controlled diet
and normal diet. There was a higher consumption of
total lipids, polyunsaturaded fatty acids and fiber in the
controlled diet, but without statistical significance.
Positive correlations were observed between weight loss
and lipids consumption (r=0.764; p=0.001) and a
negative correlation between weight loss and
carbohydrate consumption (r=-0.787; p=0.007).
Discussion
Cellulite control depends on the association of
various therapeutic interventions, due to its
multifactorial etiology, despite the unclear mecha-
nisms. Invasive and non-invasive treatments are based
on existing theories about its pathogenesis, as well as
trying to mitigate supposed aggravating factors such
as unproven changes in the dermis and hypodermis -
microcirculation and chronic inflammation. 34,35 In this
study, we opted for a non-invasive approach by
changing the dietary pattern.
The occurrence of a 56% dropout rate
illustrates the poor adherence of participants to a
restricted diet. Dropouts in clinical studies about
cellulite are frequent, due to the absence of visible
short-term results and the participant’s lack of interest in
maintaining the therapeutic proposals.27, 36 Following a
controlled diet during medium and long term, even
though providing many benefits, is difficult to mantain
considering individual habits and food preferences. 37-39
The weight and BMI at baseline, as well as the
level of physical activity corroborate with the assumption
that women who are bothered by cellulite and seek
treatment, generally with high expectations, are those
who possess healthier life habits and higher aesthetic
concern 37-39, but, whose food habits at baseline were
characterized by large amounts of high glycemic food.
Although there is no consistent evidence on
which food groups affect cellulite, the analysis of the
diet recall before the intervention showed that most
participants were used to eating industrialized food, with
high glycemic index and rich in trans fatty acids. It is
possible that these food groups can be associated with
cellulite. And the lack of vitamins and minerals, which
act as antioxidants, may also have some impact in the
Figure 3. High frequency US images of one participant,
showing an increase in dermal echogenicity in gluteal
regions by the comparison between baseline and end of
intervention

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dermis structure, as was pointed out by several
authors.18, 40-46
The photography analysis demonstrated no
significant reduction in the scores. But it has been
suggested that reducing adipose tissue, independent of
body obesity, can improve cellulite severity7,8 in healthy
persons. It depends greatly on the quality and quantity
of their daily diet.
Some studies have discussed that the
consumption of foods with high glycemic
index can accelerate the collagen tissue
glycation. 47,48 The presence of foods rich in
saturated and trans fatty acids seems to
increase fat deposition, with weight gain and
development of inflammatory processes.49 A
study conducted in 2013 compared three diets
with the same caloric intake and different
profiles of saturated fat (6%, 12%, 24%) for
16 weeks in an animal model (rat). It was
observed that the diet with 12% saturated fat
increased adiposity, inflammatory markers
and promoted metabolic dysfunction; the diet
with 24% saturated fat displayed an increase
in insulin resistance and a higher ratio of
triglycerides and LDL-cholesterol which are
known as cardiovascular risk factors.50
The controlled diet resulted in weight
loss, reduction in the skinfolds sum and
percentage of fat. It was observed, a visible
change in body composition and an increase
in dermal echogenicity, possibly by a positive
effect in collagen density and organization, in
the areas with cellulite. However, as weight
loss is distributed throughout the body, there
is no guarantee that the fat in areas affected
by cellulite was also reduced. Additionally, it is
not possible to assert that this result can
always cause improvement in the dimpled appearance of
the skin surface, as previously described in the
literature.56 However, this study, despite its limitations,
suggests that weight loss by a controlled diet may
provide structural dermal changes..
The presence of macronutrients in the controlled
diet, seems to have had a large contribution to weight
loss, as the caloric food intake was maintained.57 The
controlled diet included a higher ingestion of fat when
Controlled diet
Normal diet
0
500
1000
1500
2000
p=1,00
Calories (cal)
Controlled diet
Normal diet
0
5
10
15
20
25
p=0,63
Protein (%)
Controlled diet
Normal diet
0
20
40
60
80 p=0,19
Carbohydrate (%)
Controlled diet
Normal diet
0
10
20
30
40
50 p=0,06
Fat (%)
Controlled diet
Normal diet
0
10
20
30
40 p=0,44
Fiber (g)
Controlled diet
Normal diet
0
5
10
15
20 p=0,06
Poliunsaturated fatty acid (g)
Figure 4. Comparison of controlled diet and normal diet according
to the average of nutritional intake during the intervention.
Note: not significant values (Wilcoxon)

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compared to the normal diet. It is important to note that
this corresponded to a greater consumption of
polyunsaturated fatty acids, which may have contributed
to the weight loss.
A negative correlation was found between the
consumption of carbohydrates and weight loss. It is
probable that the participants experienced weight loss
due to the limitation of high glycemic index of processed
foods, such as pasta, sweets and desserts with added
sugar or other sweeteners.. This result is consistent with
the findings of another study that demonstrated the
greater effectiveness of a low glycemic index diet for
weight loss as compared with a low fat and higher
glycemic index.58, In addition, to maintain weight after
the initial loss, a low glycemic food load appears to be
more effective, due to the positive correlation between
low glycemic index and slower digestion, enhancing the
intake of proteins and fats as they are related to
satiety.59
In the present study, protein intake was
maintained within normal limits according to DRI,57 that
is, the controlled diet was normoproteic. Clifton et al in
a similar intervention did not demonstrate significant
difference in weight loss among participants who
followed a high proteic diet compared to a standard diet,
which is in accordance to our findings.60 However, the
influence of protein intake on weight loss remains
controversial, since other investigators have reported
that high proteic diets contribute to satiety and
consequent reduction in food consumption.61
Considering only diet and its influence on
cellulite, a study showed that a high proteic diet
combined with reduced carbohydrate consumption,
showed better response in reducing cellulite severity.
The participants followed a proteic diet also experienced
weight loss. But this diet was also rich in fat, which was
not discussed.62
Our study demonstrated that weight loss was
obtained with a diet rich in fat consumption, normal
range of reduced carbohydrates and changes oriented
only in relation to type of foods. There was a significant
increase in dermal echogenicity in gluteal regions that
could be related to an improvement in collagen tissue.
We do not have an explanation about the mechanism
involved. It is possible that a reduction in collagen
glycation and inflammation in the dermis and adipose
tissue may have occurred, despite the short time of the
intervention. The study duration was chosen so that the
results could be compared to the scarce literature
available.
The results for skin elasticity, contrary to our
expectation, were not significant. This aspect may be
related to weight loss, as it leads to metabolic
abnormalities that can compromise skin elasticity.2 Other
authors have suggested that weight loss may be
associated with changes in the dermis, the reduction of
skin elasticity and negative interference in cellulite
too.71,72 Non-invasive interventions for cellulite, in limited
period, are targeted to reduce subcutaneous fat and/or
edema and not to improve skin elasticity.
The majority of the results in this study was non
-significant. It is important to highlight the complexity in
assessing cellulite severity, the disparity between
researchers’ and participants’ opinion and, above all, the
challenge to control this common and disconfortable
disorder.
Conclusion:
This study demonstrated the efficacy of a
controlled diet in reducing weight and body composition,
accompained by a possible increase in collagen density,
despite no effect in cellulite clinical appearance.
We believe that further studies on genes related
to obesity, as well as studies on cellulite pathogenesis,
epidemiology, genetic predisposition, triggers,

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aggravating conditions, cellular and molecular
mechanisms would be useful to direct the therapy. It is
important to combine a healthy lifestyle, including diet
and exercises, with long-term non-invasive or invasive
therapeutic interventions. The successful treatment
remains distant. Unfortunately as cellulite continues to
bother women, many of them become hostages of costly
treatment proposals, most of which, without a solid
scientific basis.
Acknowledgements: for the financial support from
Foundation for the Support of Research of the State of
Sao Paulo (FAPESP) #2011/51633-8
Conflict of interest: the authors declare no conflict of
interest
Affiliations:
Departament of Dermatology - Universidade Federal de
São Paulo - UNIFESP - Brazil
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